Childhood Obesity: Analysis of the Problem and Review of Obesity Prevention Programs for Children
Jeffrey Turell, M.D.
Table of Contents
Epidemic of childhood obesity 3
Contributing factors 5
Review of programs
-Not effective 15
-No results yet 16
-Not effective 19
-No results yet 19
Prevention recommendations/guidelines 20
References for further reading 23
Works Cited 24
are in the midst of an epidemic of overweight and obesity in the
Epidemic of childhood obesity
a 2004 report by the CDC, 59 million American adults are obese, as well as 9
million children and adolescents. Obesity is the second-leading cause of
preventable death in the
Adding to the debate over the extent of the problem posed by overweight and obesity, a study released April 20, 2005 in JAMA by Flegal et al estimated that the total burden of increased mortality associated with overweight and obesity was 25,814 in the year 2000. This calculation came from the fact that the slight reduction in mortality of 86,094 deaths attributed to overweight was subtracted from the 111,909 excess deaths due to obesity. This figure is a fraction of the amount estimated by the CDC as stated above. The author attributes the difference in estimated to the use of different statistical methods, the accounting for confounding and effect modification by age, an the inclusion of mortality data from NHANES II and III. Suggested explanations for the reduced mortality estimates include advances in the treatment of cardiovascular disease and its risk factors that have led to an increase in life expectancy. Estimations stated in this paper are based on assumptions that may differ from actual practice. The results are based on BMI, not body fat percentage. Due to the increased relative risk of mortality being in the range
1-2, results can be affected by the precision and bias in relative risk estimates. At this range, numbers of deaths are very sensitive to minor changes in relative risk estimates.
Childhood obesity rates have tripled or quadrupled by age group since the 1960’s. In the National Health and Nutrition Examination Survey(NHANES) from 1963-1970, obesity rates were four and five percent for children age 6-11 and 12-19, respectively. At the last NHANES from 1999-2002, obesity rates skyrocketed to 16% for both age groups.
While this chapter
focuses on the childhood obesity epidemic in the
A report by the Institute of Medicine (IOM) has been issued that specifically addresses the phenomenon of childhood obesity, providing an assessment of the problem and recommendations. Childhood obesity is defined as “Children and youth between the ages of 2 and 18 years who have BMIs (Body Mass Index, calculated as weight in kilograms divided by height in meters squared) equal to or greater that the 95th percentile of the age- and gender-specific BMI charts developed by the CDC.”
Contributing factors to the childhood obesity epidemic
Causes of the childhood obesity epidemic include: energy imbalance, community design, poverty, school policy, family genetics and environment, and sedentary behavior.
The IOM has labeled childhood obesity a “serious national health problem requiring urgent attention and a population-based prevention approach,” noting that “Individual efforts and societal changes are needed concurrently” by federal, state and local government, industry and media, healthcare professionals, community organizations, and parents and families. The IOM reports that “Few studies test(ing) potential solutions within diverse and complex social and environmental contexts. However, the health concerns are immediate and warrant urgent preventive actions.”
The two primary causes of childhood obesity, while obvious, are lack of physical activity and poor eating habits. This phenomenon is often referred to as an energy imbalance: Too much energy (calories) consumed, with not enough being burned off by exercise and activity. Over a third of adolescents do not exercise regularly. Regarding eating habits, only 21% of children eat enough fruits and vegetables.
Sedentary living is one of the root causes of childhood obesity. This “couch-potato” lifestyle is exemplified by watching television, surfing the internet, playing video games, and driving (or being driven) everywhere. One marker for sedentary living is the proportion of students who walk or ride their bike to school regularly. Much effort has been invested into determining the proportion of “active” commuters, identifying barriers to biking or walking to school, and developing community programs to encourage and increase walking or biking to school.
In a recent study, Dr. John Sirard et al
directly observed the prevalence of walking and bicycling (active commuting) to
urban and suburban elementary schools in
Besides the obvious behavioral and biological factors involved in the rise of the obesity epidemic, it has been argued that environmental factors play a significant role as well. Once environmental factors of obesity are understood, interventions can be made to decrease or prevent obesity by changing the environment. Our current way of life has been termed “obesogenic,” defined as “the sum of influences that the surroundings, opportunities, or conditions of life have on promoting obesity in individuals or populations.” This phenomenon occurs on a macro and a micro level, and can be applied to physical, economic, political, and sociocultural environments. While this model is abstract, it certainly applies to American society: There are not enough opportunities for exercise, fast food and junk food are ubiquitous, gym memberships and eating healthy are expensive endeavors, policies permit junk food and sodas in vending machines while P.E. time has been reduced or eliminated in schools, and media bombards us with fast food commercials with food that looks better than it is actually served, always promoted by a slender person. This represents the tip of the iceberg when it comes to environmental factors related to obesity. Fortunately, just as there are obesogenic environments, there are “leptogenic,” environments that promote physical activity and healthy eating habits.
Just as in all other aspects of society, innate differences between youth and adults must be accounted for in urban design. Primarily, youth spend the majority of their day at school and in transit between home and school. Urban planners must bear this in mind as they design “smart growth” communities with more sidewalks and street crossings meant to promote physical activity and combat urban sprawl. Even more, urban planners must consider the unique needs of both young children (playgrounds) and adolescents (bike paths and crosswalks). Krizek et al have developed a schematic to better characterize the activity patterns of youth in relation to community design.
The disparate fields of epidemiology and transportation behavioral analysis have a shared goal of increasing physical activity for different reasons: Epidemiologists wish to reduce adverse health outcomes associated with physical inactivity, and transportation planners must comply with the Clean Air Act amendments of 1990 to reduce the amount of travel by private automobile. One strategy that could become a sustainable way to achieve recommended levels of physical activity is to promote what is termed “utilitarian” walking, in which one walks to accomplish a task, travel to a destination, or run an errand. An integration of these fields in analysis of data and study design may enhance understanding of the role of urban and transportation factors on physical activity and health outcomes.
School policy has a significant effect on the health of children and adolescents, who spend a significant part of their lives in school. On the nutrition side, school cafeterias serve food that is of both low quality and low nutritional value. In addition, consumption of junk food and soft drinks from vending machines compounds the problem. On the physical activity side, there has been a reduction in time allotted for both recess and physical education classes.
At home, leisure time is now dominated by “screen” time (TV, computer, video games, etc.). While recommendations are to spend no more than 2 hours per day on screen time, it is not uncommon for children to spend over 4 hours a day devoted to screen time. The use of leisure time on sedentary activities leaves little or no time for physical activity.
from the 2000 U.S. Census, the 2002 Behavioral Risk Factor and Surveillance
Survey, and the 2002 U.S. Yellow pages, a cross-sectional study was performed by
Maddock to assess the relationship between fast food restaurants and state
obesity levels. State obesity rates
range from 16.5% of Coloradoans to 27.6% of
Advertising by fast food, junk food, and soft drink corporations drives the consumption of their products. Children are bombarded by messages to “supersize” their meal, adding both fat and calories. Advertising is a double-whammy, in that children watch the commercial on television as part of their sedentary behavior, and are influenced in their decision to consume a product which nutritionally is a poor choice.
In many cases, obesity runs in families. Or, in the case of overweight children, their parents are the ones buying and preparing food at home and paying for food eaten outside the home. Given these facts, it seems reasonable to involve families in the program. One study showed that both mothers and their adolescent daughters benefit from participation in either community or home-based physical activity programs.
study, conducted at Tel Aviv Univerity’s Sackler School of Medicine in
Consequences of Obesity
To emphasize the scope of the problem, the
IOM reports that “The obesity epidemic affects both boys and girls and has
occurred in all age, race, and ethnic groups throughout the
Being overweight or obese(BMI of > 25 or 30, respectively) puts one at increased risk of: premature death, diabetes mellitus- type 2, heart disease, stroke, hypertension, hypercholesterolemia, cholelithiasis, osteoarthritis, sleep apnea, asthma, cancer of the endometrium, colon, kidney, breast, and gallbladder, menstrual irregularities and gestational problems, hirsutism, urinary incontinence, and orthopedic problems, among others. Based on this troubling information, Healthy People 2010 listed overweight and obesity as major public health problems with target recommendations. In regards to diabetes, approximately 30% of boys and 40% of girls born this millennium are at risk for developing diabetes mellitus at some point in their lifetime.
A recent journal article specified the health risks of an elevated BMI in childhood and adolescence, stating, “During the past decade an increase in the prevalence of type 2 diabetes in adolescents has been observed. The association of type 2 diabetes and obesity is well established and most adolescents with type 2 diabetes have body mass index in a range that would already be considered obese in an adult. Childhood overweight is also associated with the atherosclerotic process.” Thus, type 2 diabetes, once considered a disease of middle age, is now encompassing adolescents too. In addition, the foundation for heart disease is being laid down as early as childhood.
economic consequences of obesity and sedentary living in the
Medicare expenditures have been found to be positively correlated with elevated BMI measured earlier in life. In a study looking at Medicare claims between 1984 to 2002 after previous baseline screening by the Chicago Heart Association between 1967 and 1973, all health care charges were totaled and annualized for each participant. Subjects were categorized by BMI as non-overweight, overweight, obese, and severely obese. Among men, a significant positive relation was observed between BMI and inpatient and outpatient hospital-related Medicare charges. Charges for severely obese men were 84% higher than for non-overweight men. A similar phenomenon was found in the women as well. For patients aged 65 to 83 years, when followed until death, their cumulative CVD-related, diabetes-related, and total Medicare charges, adjusted for age, race, education, and smoking were higher with higher BMI. For the men in the study, there was a statistically significant positive, direct association between BMI and average annual number of hospital visits and hospital days. In 2003, about 7% of Medicare expenditures were attributable to obesity. The study concluded with a warning, stating, “With current trends of increasing overweight and obesity afflicting all age groups, urgent preventive measures are required not only to lessen the burden of disease and disability associated with excess weight but also to contain future health care costs incurred by the aging population. Public health efforts need to include comprehensive national strategies and resources for primary prevention of weight gain from early life on, with the goal to contain and end the obesity epidemic and reduce health care costs among older persons.
Overweight and obese children may experience depression due to concerns over their body image. They may be teased and bullied by their peers. Low self-esteem and a preoccupation with body image may prevent obese children from participating in sports and other activities. As obesity tracks from childhood to adulthood, they may experience discrimination in the workforce and social marginalization.
Review of childhood obesity prevention programs
a. School-based interventions
Fitzgerald conducted a survey of schools in the
Bayne-Smith et al
compared The Physical Activity and Teenage Health (PATH) Program to traditional
PE classes for urban teenage girls in three
Addressing nutritional content of food in schools, the TACOS(Trying Alternative Cafeteria Options in Schools) study, conducted by French et al, looked at the effect of increasing availability of lower-fat foods in a la carte cafeteria items and student-led promotion of healthy food choices. The TACOS study occurred in 20 secondary schools in the Minneapolis-St. Paul metropolitan area that were randomly assigned to the environmental intervention program or the no-intervention control site over a two-year period. Results of the study show that the intervention schools had more availability of a la carte foods that were lower in fat as well as a significantly higher percentage of sales from lower fat a la carte foods. The success of the TACOS program demonstrates that making changes in the school food environment to increase availability and awareness of healthier foods had a significant impact on the sale of those foods to students.
To assess the
utility of screening for childhood obesity, a school-based obesity screening
program for fifth graders was initiated in
as part of the CARDIAC(Coronary Artery Risk Detection in Applalachian Communities) study. In this community, as determined by survey, 11% of children lacked health insurance, demonstrating a need to conduct obesity screening in locations other than physician offices. Approximately 45% of the children studied were either overweight or obese. Obesity was associated with a significant increase in lipid levels and blood pressure. By parental report, only 63% of obese children and 26% of overweight children were identified by their physician as being at an elevated weight proportionate to their height and age. The intervention was relatively inexpensive and minimally invasive to implement. The information obtained from universal childhood obesity screening can alert children, parents, and physicians to the problem of obesity so that a plan of action can be formulated to address the problem.
ii. Programs that don’t work
One such program is called New Moves, an obesity prevention program for adolescent girls. New Moves “was offered as a girls-only alternative physical education program that high-school girls took for credit.” The program was based on social cognitive theory. Components of the 16-week program include physical activity, nutrition and social support sessions. There was a parental component focusing on increasing support of the girls. A follow-up at 8 months post-intervention was performed to compare to baseline. There were no differences in BMI between the groups at post-intervention or follow-up, but there was a significant difference of progression of stage of change for physical activity in the intervention group compared to the control group.
“The Child and Adolescent Trial for Cardiovascular Health (CATCH) was a NHLBI-sponsored multi-center, school-based intervention study promoting healthy eating, physical activity, and tobacco non-use by elementary school children.” The study was presented as one of several articles on the program in an issue of “Preventive Medicine.” The articles reviewed the effects of school PE class, parental involvement, psychosocial determinants of diet and exercise, changes in cardiovascular risk factors, and maintenance of diet and exercise 3 years after the study ended. The program was based on social cognitive theory. This randomized trial included 5106 children from 4 states of multi-ethnic backgrounds, and 4019 of them were available for follow-up (79%). The authors concluded that although there was a statistically significant difference in eating and physical activity behavior, there was not significant improvement in BMI, blood pressure, or blood chemistry. Interestingly, there were differential effects of the program on BMI and lipid profile when comparing race and gender. The behavioral changes were sustained at 3 year follow-up.
iii. Programs yet to be evaluated
Girls health Enrichment Multi-site Studies (GEMS) investigates novel approaches to obesity prevention in young African American girls, with a cohort of 9-10 year old African American and white girls. GEMS is a “multi-site research program created to develop and test interventions to prevent obesity in African-American pre-adolescent girls.” This is an ongoing two-phase study sponsored by the NHLBI. In Phase 1, different interventions were initiated at the individual centers of the trial, with the outcome being prevention of excessive weight gain. The effectiveness of each intervention will be evaluated, and the intervention that is most effective will be applied to the rest of the centers in Phase 2.
‘Pathways’ is “a culturally appropriate obesity-prevention program for American Indian schoolchildren.” It studies a group that did not have any pre-existing evidence on youth obesity prevention, and undertook a feasibility study prior to enacting the program to better understand American Indian beliefs and behaviors. Pathways is based on social learning theory. The four areas of Pathways include a classroom component, PE, parental involvement, and nutrition in the cafeteria. While there are no results in this part of the study, it is instructive to see the preparation that went into developing the program.
Hip-Hop to Health Jr. is “an obesity
prevention program for preschool minority children” funded by the NHLBI of the
NIH. The program is integrated into Head
Start programs in
new study currently underway in
b. Community-based interventions
i. Programs that work
Committed to Kids is a program for overweight adolescents and their families conducted weekly in an outpatient setting. The four components of the program involve medical, psychosocial, nutrition, and exercise interventions. The sessions were 2 hours in duration. The participants were provided a specific nutrition and exercise program based on their initial level of obesity. Each participant was given an initial medical evaluation with quarterly checkups. The program lasted for one year. By the end of the year, participants reduced their mean BMI from 32.3 to 28.2, and the percentage of their mean ideal body weight from 177 to 141.9. Factors contributing to the success of the program include: An entertaining curriculum that leads to weight loss, involvement of families, and quarterly feedback.
As part of a
multidisciplinary outpatient pediatric weight management program, Sothern et al
studied the use of a resistance training exercise program. The overall program included nutrition,
exercise, and behavior modification.
Over a one year period, no injuries were reported related to the
prescribed exercise program. At one
year, total body weight, percent of ideal body weight, BMI, and percent body
fat were significantly decreased from baseline.
This study supports the recommendation of the
ii. Programs that don’t work
A review of 14 interventions to prevent childhood obesity by Castano et al included two community-based programs: Stanford GEMS pilot study by Robinson and an intervention for African-American mothers and their daughters by Stolley. Both programs lasted 3 months and included behavioral modification, physical activity, and parental involvement; in addition, the study by Stolley et al included nutritional education. After 3 months, there was no statistically significant change in BMI for either program. In the GEMS pilot, however, there was a reduction in the amount of time spent watching television.
iii. Programs that have yet to be evaluated
An initiative in
In response to the report by the CDC that
obesity has become the second-leading cause of preventable death in the
The epidemic of childhood obesity has serious health, economic, and social repercussions for individuals and for the nation. Prevention of obesity works better than treatment of obesity, and prevention should begin in early childhood. There are many factors outside the realm of individual behavior that contribute to the “obesogenic” environment, and these issues must be addressed in a multidisciplinary way at all levels of government and society. Some successful childhood obesity prevention and treatment programs have been identified; others, while well intentioned, have not proven to be effective. Furthermore, some are still underway and should be monitored closely.
Lastly, it should be noted that all of the obesity prevention programs generally follow the same format and recommendations. It may be that radical, new approaches to childhood obesity prevention are needed. Some suggestions:
-Eliminate school bus service for children who live less than two miles from school. Of course, safe school walk/bike routes will have to be established for this to be successful.
-Make P.E. mandatory for grades 1-12, one hour a day.
-Make of physical activity standards part of the college admission process.
-Screen all children for elevated BMI at each doctor visit and annually at school, sending all overweight children to a local, successful childhood obesity prevention and treatment program that is covered by insurance.
-T.V.’s that either run on bicycle, rowing, or jogging in place. In addition, the television would be set for a maximum of 2 hours use per day. The amount of TV time could alternatively be set to the amount of exercise done per day, measured by a pedometer or other device. A child who exercises for an hour gets to watch one hour of TV or surf the web for 1 hour or play one hour of video games. Each of these machines would have a device to know how much time the child has accrued, and shuts off once the time has expired.
-Build modern sports and fitness centers throughout each community that will provide a safe environment. Charge nothing. The future savings of fewer healthcare dollars spent on obesity-related disease management will pay for the facilities and staff.
-Take vending machine color-coding of snacks and beverages one step further. On each student’s ID card, incorporate into the magnetic strip parental restrictions on what their children can buy and how much. Children will not be able to buy anything from the vending machine until parents inform the school of their preferences. Pretty soon, snack companies will change what they offer in vending machines, realizing they can make the same amount of money or more selling healthier foods and beverages.
-Upgrade the public school meal program to use only the highest quality foods, serving a healthy breakfast and lunch to students. The food should be fresh, tasty, healthy, and affordable, with no unhealthy choices on the menu to lead children astray.
References for further reading
a. Nelson’s Textbook of Pediatrics, 17th edition
b. Preventing Childhood Obesity: Health
in the Balance.
c. “Obesity” issue of American Journal of Public Health, September 2004.
Surgeon General’s Call To Action To Prevent and Decrease Overweight and Obesity
2001, U.S. Department of Health and Human Services, Public Health Service,
Office of the Surgeon General.
2 CDCP. 2004. At a Glance.
Physical Activity and Good Nutrition: Essential Elements to Prevent Chronic
Diseases and Obesity 2004.
January 19,2005- Vol 293, No.3, “Correction: Actual Causes of Death in the
 Flegal, Graubard, Williamson, and Gail. “Excess Deaths Associated with Underweight, Overweight, and Obesity. JAMA. 2005; 293(15): 1861-1867.
8 IOM, September 2004. Overview of the IOM’s Childhood Obesity Prevention Study. Excerpt from Preventing Childhood Obesity: Health in the Balance, 2005.
9 CDCP. 2004.
At a Glance. Physical Activity and Good Nutrition: Essential Elements to
Prevent Chronic Diseases and Obesity 2004.
American Journal of Public Health. 2005; 95: 236-237. “Prevalence of Active Commuting at Urban and
Suburban Elementary Schools in
American Journal of Health Promotion.
2004; 19(2): 128-136.
“Neighborhood Design and Rates of Walking and Biking to Elementary
School in 34
12 Swinburn, Egger, Raza. 1999 Dec. Dissecting Obesogenic Environments: The Development and Application of a Framework for Identifying and Prioritizing Environmental Interventions for Obesity. Preventive Medicine. 29(6 Pt 1):563-570.
 American Journal of Health Promotion. 2004; 19(1):33-38. “A Schematic for Focusing on Youth in Investigations of Community Design and Physical Activity.” Krizek, Birnbaum, Levinson.
 American Journal of Health Promotion. 2004; 19(1): 39-44. “When Worlds Collide: Observations on the Integration of Epidemiology and Transportation Behavioral Analysis in the Study of Walking.” Coogan, P. and Coogan, M.
 American Journal of Health Promotion. 2004;19(2): 137-143. “The Relationship Between Obesity and the Prevalence of Fast Food Restaurants: State-Level Analysis.” Maddock.
 Drewnowski, Darmon, and Briend. “Replacing Fats and Sweets with Vegetables and Fruits- A Question of Cost.” American Journal of Public Health. 2004; 94(9): 1555-1559.
IOM, September 2004. Childhood Obesity in the
IOM, September 2004. Childhood Obesity in the
 Pediatric Blood Cancer. 2005. Feb 7. “Regulation of body mass and management of childhood overweight.” Daniels, SR.
 IOM, September 2004. Overview of the IOM’s Childhood Obesity Prevention Study. Excerpt from Preventing Childhood Obesity: Health in the Balance, 2005.
 JAMA, December 8, 2004- Vol 292, No. 22. “Relation of Body Mass Index in Young Adulthood and Middle Age to Medicare Expenditures in Older Age. Daviglus, Liu, Yan, et al.
IOM, September 2004. Childhood Obesity in the
 Veugelers and Fitzgerald. “Effectiveness of School Programs in Preventing Childhood Obesity: A Multilevel Comparison.” American Journal of Public Health. 2005; 95(3): 432-435.
 Bayne-Smith, Fardy, Azzollini, Magel, Schmitz, and Agin. “Improvements in Heart Health Behaviors and Reduction in Coronary Artery Disease Risk Factors in Urban Teenaged Girls Through a School-Based Intervention: The PATH Program.” American Journal of Public Health. 2004; 94(9): 1538-1543.
 French, Story, Fulkerson, and Hannan. “An Environmental Intervention to Promote Lower-Fat Food Choices in Secondary Schools: Outcomes of the TACOS Study.” American Journal of Public Health. 2004; 94(9): 1507-1512.
Demerath, Muratova, Spangler, Li, Minor, Neal.
“School-based obesity screening in rural
32 Nader, Stone, Lytle, et al. 1999 Jul. Three-Year Maintinence of Improved Diet and Physical Activity: The CATCH Cohort. Archives of Pediatric Adolescent Medicine. 153: 695-704.
34 Davis, Going, Helitzer, et al. 1999 Apr. Pathways: a culturally appropriate obesity-prevention program for American Indian schoolchildren. American Journal of Clinical Nutrition. 69(4 S): 767S-772S.
 Yin, Janes, Moore, Humbles, Barbeau, and Gutin. “An After-School Physical Activity Program for Obesity Prevention in Children.” Evaluation and the Health Profession. 2005; 28(1): 67-89.
Sothern, Schumacker, von Almen,
Sothern, Loftin, Udall, Suskind,
 Castano, Doreste, and Serra-Majem. “Effectiveness of interventions in the prevention of childhood obesity.” European Journal of Epidemiology. 2004; 19: 617-622.
 Pediatric Update. Winter 2005. Volume 2, Issue 1. “Rainbow Pilot Research Program Targets Growing Obesity Epidemic in Children.”
“Prevention of Pediatric Overweight and Obesity.” Policy Statement of The
a. BMI calculator
1. Weight in kilograms / height in m²
2. Weight in pounds / height in inches² * 703
b. BMI chart for girls and boys, ages 2-20, 5th to 95th percentile; see pp.27-28